Provider Demographics
NPI:1295268381
Name:WELLS, DAVID MICHAEL (FNP)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:MICHAEL
Last Name:WELLS
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:429 W OLIVE ST
Mailing Address - Street 2:
Mailing Address - City:STAUNTON
Mailing Address - State:IL
Mailing Address - Zip Code:62088-1335
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:800 E CARPENTER ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62769-3810
Practice Address - Country:US
Practice Address - Phone:217-544-6464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-06
Last Update Date:2021-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.015796363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner